Schedule of Benefits Dental Phoenix Health Plans, Inc.
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- Richard Norton
- 7 years ago
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1 Your Policy gives You important information about Your health care benefits. It includes information such as Pre-Authorization requirements. This Schedule of Benefits Dental is issued to You with Your Policy. It summarizes Your dental services benefits. Please keep Your Schedule of Benefits Dental with Your Policy. will notify You if any changes are needed. We are partnering with DentaQuest of Arizona, LLC (DentaQuest) to provide the dental services that are covered under this plan. If You have any questions about the dental services covered under this plan, please call Our Customer Service Department at (855) or TTY: (855) Getting Dental Services DentaQuest contracts with dentists to provide dental services to Members. These contracted dentists are referred to as Participating Dentists in this Schedule of Benefits Dental. Our provider directory has a list of Participating Dentists. To find a Participating Dentist, visit: You may schedule appointments by calling a participating general dental office directly. Be sure to check that the dental office is participating with Us and DentaQuest before making each dental appointment and before receiving services. You must get Pre-Authorization before getting dental services. Call Our Customer Service Department or the Pre-Authorization Hotline at (855) or TTY: (855) to be sure the proposed service has received Pre-Authorization before getting the service. It is important to keep Your scheduled appointments. If You need to cancel, please call the dental office within 24 hours before Your scheduled visit. You are responsible for any fees for missed appointments. Specialist Services DentaQuest contracts with dental specialists in all fields: oral surgeons for extractions, periodontists for treatment of the gums, endodontists who specialize in root canals, and pedodontists and orthodontists for children. Please call Our Customer Service Department for more information if You need help finding a dental specialist. Emergency Services Members are covered for emergency dental services at participating dental offices. If You have a dental emergency, please call a participating dental office. If the office is not available immediately, call Us for assistance with obtaining an emergency appointment. In case of an acute emergency, seek immediate hospital care. Emergency office visits may be subject to additional charges. Members are also covered for emergency dental services while temporarily more than 50 miles from a Participating Dentist. Palliative treatment should be obtained from a licensed dentist and payment made for services rendered _PHP_SOBDental_2016 1
2 Members are reimbursed the usual and customary fees for covered dental services, subject to any applicable fees, not exceeding $100 per claim. To receive reimbursement, You must submit the following information within 90 days of the date of service: Paid receipt Member s name ID number Address Phone number Policy Holder s name and ID number Any other supporting documentation necessary to process the reimbursement NOTE: Palliative (emergency) treatment of dental pain minor Member Cost Sharing Pediatric Members Pediatric dental services are available to Members through the month of their 19 th birthday. Class I services are covered in full with no Deductible. Class II, Class III and Class IV services are covered at Coinsurance after a $100 Deductible. (The Deductible only applies to Classes II through IV.) Once the Member reaches the applicable integrated medical, drug and pediatric dental Annual Maximum Out-of-Pocket amount, the plan will cover 100% of costs for all Covered Services. (Please see Your Schedule of Benefits for the applicable Annual Maximum Out-of-Pocket.) Adult Members Adult dental services are available to Members age 19 and older. Class I services are covered in full with no Deductible. Class II services are covered at Coinsurance after a $100. (The Deductible applies to Class II only.) The plan will cover up to $500 in Covered Services per Plan Year. NOTE: There is no coverage for Class III or Class IV services. See Covered Services below for more information on what services are covered under this plan. There is no out of network coverage except in the case of emergencies (see Emergency Services above for more information). You are responsible for the entire cost of the service if You see a nonparticipating dentist. NOTE: Information on cost sharing and zero and limited cost share plan variants: The adult dental Services covered under this plan are not Essential Health Benefits. The adult dental Services covered under this plan are subject to the cost sharing amounts outlined in this Schedule of Benefits Dental. The pediatric dental Services covered under this plan are Essential Health Benefits. Cost sharing for pediatric dental Services are as follows: For Members enrolled in a zero cost share plan variations: There is no cost sharing for covered pediatric dental Services received from an Indian Health Service dental provider or 65441_PHP_SOBDental_2016 2
3 Participating Dentist. Schedule of Benefits Dental For Members enrolled in a limited cost share plan variations: There is no cost sharing for covered pediatric dental Services provided by an Indian Health Service dental provider. You must get a referral from Purchased/Referred Care (formerly Contract Health Services) to avoid cost sharing for covered pediatric dental Services with any other Participating Dentists. Please see Your Policy for more information about zero and limited cost share plans. If You have any questions, please contact Our Customer Service Department. Covered Services This Schedule of Benefits Dental lists all of the dental services, procedures, treatment and supplies that are covered under this plan, the cost (if any) for each covered procedure and any Benefit Maximums (limitations) that apply to each Covered Service. Services covered under this plan are identified by current dental terminology (CDT) code. Please see the following sections in this Schedule of Benefits Dental for services by CDT codes covered under this plan: Covered Services Pediatric Dental Services: (1) Class I Services: Diagnostic and Preventive Services (2) Class II Services: Restorative and Other Basic Dental Services (3) Class III Services: Complex and Major Restorative Dental Services (4) Class IV Services: Orthodontic Services (Medically Necessary Orthodontic Treatment) Covered Services Adult Dental Services: (1) Class I Services: Diagnostic and Preventive Services (2) Class II Services: Restorative and Other Basic Dental Services CDT codes not listed are excluded from coverage under this plan. Covered Services are available only while You are covered under this plan. You are responsible for payment for any services not covered under this plan. Services are subject to Pre-Authorization or review by DentaQuest and/or Us. An alternate benefit may be paid. You have the right to benefits on a non-discriminatory basis for the Covered Services listed in this Schedule of Benefits Dental. Please note that benefits and coverage may vary based on patient s age at date of service. Pediatric Dental Services Pediatric dental benefits are available for Members through the month of their 19 th birthday. This plan includes coverage of pediatric dental services as required under the PPACA _PHP_SOBDental_2016 3
4 (1) Class I Services: Diagnostic and Preventive Services Benefits are available for the following dental services to diagnose or to prevent tooth decay and other forms of oral disease: Class I Services: Diagnostic and Preventive Services D0120 Periodic oral evaluation established Once in 6 $0 patient D0140 Limited oral evaluation problem focused Once in 6 D0150 Comprehensive oral evaluation new or Once in 6 established patient D0180 Comprehensive periodontal evaluation Once in 6 new or established patient D0210 Intraoral complete set of radiographic images Once in 60, including bitewings D0220 Intraoral periapical first radiographic image D0230 Intraoral periapical each additional radiographic image D0240 Intraoral occlusal radiographic image D0270 Bitewing single radiographic image 1 set every 6 D0272 Bitewings two radiographic images 1 set every 6 D0274 Bitewings four radiographic images 1 set every 6 D0277 Vertical bitewings 7 to 8 radiographic 1 set every 6 images D0330 Panoramic radiographic image Once in 60 D0470 Diagnostic casts D1110 Prophylaxis over age 14 Once in 6 D1120 Prophylaxis ages 1-13 Once in 6 D1206 Topical application of fluoride varnish Twice in 12 D1208 Topical application of fluoride Once in 6 D1351 Sealant per tooth Once per tooth per 36 on occlusal surface of permanent D1352 D1510 D1515 D1520 D1525 D1550 D9110 Preventive resin restoration in a moderate to high caries risk patient permanent tooth Space maintainer fixed unilateral Space maintainer fixed bilateral Space maintainer removable unilateral Space maintainer removable bilateral Re-cementation of space maintainer Palliative (emergency) treatment of dental pain minor procedure molars Once per tooth per 36 on occlusal surface of permanent molars 65441_PHP_SOBDental_2016 4
5 (2) Class II Services: Restorative and Other Basic Dental Services Benefits are available for the following dental services to treat oral disease: Class II Services: Restorative and Other Basic Dental Services D0391 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report Amalgam one surface, primary or permanent Amalgam two surfaces, primary or permanent Amalgam three surfaces, primary or permanent Amalgam four or more surfaces, primary or permanent Resin-based composite one surface, anterior Resin-based composite two surfaces, anterior Resin-based composite three surfaces, anterior Resin-based composite four or more surfaces or involving incisal angle (anterior) D2910 Recement inlay, onlay or partial coverage restoration D2920 Recement crown D2929 Prefabricated porcelain/ceramic crown primary tooth D2930 Prefabricated stainless steel crown primary tooth D2931 Prefabricated stainless steel crown permanent tooth D2940 D2951 Protective restoration Pin retention per tooth, in addition to restoration Once per tooth per 24 on anterior primary teeth Under age 15 limited to once per tooth per 60 Under age 15 limited to once per tooth per 60 Coinsurance Deductible 65441_PHP_SOBDental_2016 5
6 Class II Services: Restorative and Other Basic Dental Services D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament D3222 Partial pulpotomy for apexogenesis permanent tooth with incomplete root development D3230 Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) posterior, primary tooth (excluding final restoration) Limited to primary incisor teeth form members up to age 6 and for primary molars and cuspids up to age 11 and is limited to one per tooth per lifetime Limited to primary incisor teeth form members up to age 6 and for primary molars and cuspids up to age 11 and is limited to one per tooth per lifetime Limited to primary incisor teeth form members up to age 6 and for primary molars and cuspids up to age 11 and is limited to one per tooth per lifetime Limited to primary incisor teeth form members up to age 6 and for primary molars and cuspids up to age 11 and is limited to one per tooth per lifetime D4341 Periodontal scaling and root planing four or more teeth per quadrant Limited to 1 every 24 D4342 Periodontal scaling and root planing one to three teeth per quadrant Limited to 1 every 24 D4910 Periodontal maintenance 4 in 12 combined with adult prophylaxis after the completion of active periodontal therapy D5410 Adjust complete denture maxillary D5411 Adjust complete denture mandibular D5421 Adjust partial denture maxillary D5422 Adjust partial denture mandibular D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth per tooth D5650 Add tooth to existing partial denture Coinsurance Deductible 65441_PHP_SOBDental_2016 6
7 Class II Services: Restorative and Other Basic Dental Services D5660 Add clasp to existing partial denture D5710 Rebase complete maxillary denture (after 6 have elapsed since initial placement) D5720 Rebase maxillary partial denture (after 6 have elapsed since initial placement) D5721 Rebase mandibular partial denture (after 6 have elapsed since initial placement) D5730 D5731 Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) after 6 elapsed. (3 from after 6 elapsed. (3 from D5740 Reline maxillary partial denture (chairside) after 6 elapsed. (3 from D5741 D5750 Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) after 6 elapsed. (3 from after 6 elapsed. (3 from Coinsurance Deductible 65441_PHP_SOBDental_2016 7
8 Class II Services: Restorative and Other Basic Dental Services D5751 D5760 D5761 Reline complete mandibular denture (laboratory) Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) after 6 elapsed. (3 from after 6 elapsed. (3 from after 6 elapsed. (3 from D5850 Tissue conditioning, maxillary Not allowed within 6 of initial placement D5851 Tissue conditioning, mandibular Not allowed within 6 of initial placement D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7270 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Removal of impacted tooth soft tissue Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony, with unusual surgical complications Surgical removal of residual tooth roots (cutting procedure) Coronectomy intentional partial tooth removal Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Coinsurance Deductible 65441_PHP_SOBDental_2016 8
9 Class II Services: Restorative and Other Basic Dental Services D7280 Surgical access of an unerupted tooth D7310 D7311 D7320 D7321 D7471 Alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per quadrant Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant Removal of lateral exostosis (maxilla or mandible) D7510 Incision and drainage of abscess intraoral soft tissue D7910 Suture of recent small wounds up to 5 cm Individual consideration D7921 D7971 D9220 D9221 D9241 D9242 D9310 D9610 D9930 Collection and application of autologous blood concentrate product Excision of pericoronal gingiva Deep sedation/general synesthesia first 30 minutes Deep sedation/general anesthesia each additional 15 minutes Intravenous conscious sedation/analgesia first 30 minutes Intravenous conscious sedation/analgesia each additional 15 minutes Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician Therapeutic parenteral drug, single administration Treatment of complications (post-surgical) unusual circumstances, by report Individual consideration Coinsurance Deductible 65441_PHP_SOBDental_2016 9
10 (3) Class III: Complex and Major Restorative Dental Services Benefits are available for the following dental services and supplies to treat oral disease: Class III Services: Complex and Major Restorative Dental Services D0160 D2510 Detailed and extensive oral evaluation problem focused, by report Inlay metallic one surface D2520 Inlay metallic two surfaces D2530 Inlay metallic three or more surfaces D2542 Onlay metallic two surfaces D2543 Onlay metallic three surfaces D2544 Onlay metallic four or more surfaces D2740 Crown porcelain/ceramic substrate D2750 Crown porcelain fused to high noble metal D2751 Crown porcelain fused to predominantly base metal D2752 Crown porcelain fused to noble metal D2780 Crown 3/4 cast high noble metal D2781 Crown 3/4 cast predominantly base metal D2783 Crown 3/4 porcelain/ceramic D2790 Crown full cast high noble metal D2791 Crown full cast predominantly base metal D2792 Crown full cast noble metal D2794 Crown - titanium D2950 Core buildup, including any pins when D2954 D2980 required Prefabricated post and core in addition to crown Crown repair necessitated by restorative material failure 65441_PHP_SOBDental_
11 Class III Services: Complex and Major Restorative Dental Services D2981 D2982 D2983 D2990 D3310 D3320 D3330 D3346 D3347 D3348 D3351 D3352 D3353 D3410 D3421 D3425 D3426 D3450 D3920 D4210 Inlay repair necessitated by restorative material failure Onlay repair necessitated by restorative material failure Veneer repair necessitated by restorative material failure Resin infiltration of incipient smooth surface lesions Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) Retreatment of previous root canal therapy anterior Retreatment of previous root canal therapy bicuspid Retreatment of previous root canal therapy molar Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) Apexification/recalcification interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) Apexification/recalcification final visit (includes completed root canal therapy apical closure/calcific repair of perforations, root resorption, etc.) Apicoectomy anterior Apicoectomy bicuspid (first root) Apicoectomy molar (first root) Apicoectomy (each additional root) Root amputation per root Hemisection (including any root removal), not including root canal therapy Gingivectomy or gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant Once per year per tooth after 24 of crown insertion Once per quadrant per _PHP_SOBDental_
12 Class III Services: Complex and Major Restorative Dental Services D4211 D4212 D4240 D4249 D4260 D4270 D4273 D4277 D4278 D4355 Gingivectomy or gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap procedure, including root planing, four or more contiguous teeth or tooth bounded spaces per quadrant Clinical crown lengthening hard tissue Osseous surgery (including flap entry and closure) four or more contiguous teeth or tooth bounded spaces per quadrant Pedicle soft tissue graft procedure Subepithelial connective tissue graft procedures, per tooth Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site Full mouth debridement to enable Once per quadrant per 36 Once per quadrant per 36 Once per quadrant per 36 Once per site/tooth per 36 on the buccal surfaces of natural only. Not to exceed two sites/teeth per quadrant per 36 Two teeth per quadrant per 36 month on natural teeth only Once per lifetime comprehensive evaluation and diagnosis D5110 Complete denture maxillary Once per arch per 60 D5120 Complete denture mandibular Once per arch per 60 D5130 Immediate denture maxillary Once per arch per 60 D5140 Immediate denture mandibular Once per arch per 60 D5211 D5212 Maxillary partial denture resin base (including any conventional clasps, rests and teeth) Mandibular partial denture resin base (including any conventional clasps, rests and teeth) Once per arch per 60 Once per arch per _PHP_SOBDental_
13 Class III Services: Complex and Major Restorative Dental Services D5213 D5214 Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5281 Removable unilateral partial denture one piece cast metal Once per arch per 60 Once per arch per 60 Once per arch per 60. Not to be combined with any other denture in the same arch Once every 60 D6010 Surgical placement of implant body endosteal implant D6012 Surgical placement of interim implant Once every 60 body for transitional prosthesis endosteal implant D6040 Surgical placement eposteal implant D6050 Surgical placement transosteal implant D6053 D6054 D6055 D6056 D6058 D6059 D6060 D6061 D6062 D6063 D6064 Implant/abutment supported removable denture for completely endentulous arch Implant/abutment supported removable denture for partially edentulous arch Connecting bar implant supported or abutment supported Prefabricated abutment includes modification and placement Abutment supported porcelain/ceramic crown Abutment supported porcelain fused to metal crown (high noble metal) Abutment supported porcelain fused to metal crown (predominantly base metal) Abutment supported porcelain fused to metal crown (noble metal) Abutment supported cast metal crown (high noble metal) Abutment supported cast metal crown (predominantly base metal) Abutment supported cast metal crown (noble metal) Once per 60 per arch Once per 60 per arch 65441_PHP_SOBDental_
14 Class III Services: Complex and Major Restorative Dental Services D6065 D6066 D6067 D6068 D6069 D6070 D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6080 D6090 Implant supported porcelain/ceramic crown Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) Implant supported metal crown (titanium, titanium alloy, high noble metal) Abutment supported retainer for porcelain/ceramic FPD Abutment supported retainer for porcelain fused to metal FPD (high noble metal) Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) Abutment supported retainer for porcelain fused to metal FPD (noble metal) Abutment supported retainer for cast metal FPD (high noble metal) Abutment supported retainer for cast metal FPD (predominantly base metal) Abutment supported retainer for cast metal FPD (noble metal) Implant supported retainer for ceramic FPD Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy or high noble metal) Implant supported retainer for cast metal FPD (titanium, titanium alloy or high noble metal) Implant/abutment supported fixed denture for completely edentulous arch Implant/abutment supported fixed denture for partially edentulous arch Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments Repair implant supported prosthesis, by report One per tooth per _PHP_SOBDental_
15 Class III Services: Complex and Major Restorative Dental Services D6091 Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment D6095 Repair implant abutment, by report D6100 Implant removal, by report D6101 D6102 D6103 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closure Bone graft for repair of perrimplant defect not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration D6104 Bone graft at time of implant placement D6190 Radiographic/surgical implant index, by report D6210 Pontic cast high noble metal D6211 Pontic cast predominantly base metal D6212 Pontic cast noble metal D6214 Pontic titanium D6240 Pontic porcelain fused to high noble metal D6241 Pontic porcelain fused to predominantly base metal D6242 Pontic porcelain fused to noble metal D6245 Pontic porcelain/ceramic as an alternate benefit for porcelain fused to metal pontic (D6240) D6545 Retainer cast metal for resin bonded fixed prosthesis 65441_PHP_SOBDental_
16 Class III Services: Complex and Major Restorative Dental Services D6548 D6740 Retainer porcelain/ceramic for resin bonded fixed prosthesis Crown porcelain/ceramic D6750 Crown porcelain fused to high noble metal D6751 Crown porcelain fused to predominantly base metal D6752 Crown porcelain fused to noble metal D6780 Crown 3/4 cast high noble metal D6781 Crown 3/4 cast predominantly base metal D6782 Crown 3/4 cast noble metal D6783 Crown 3/4 porcelain/ceramic D6790 Crown full cast high noble metal D6791 Crown full cast predominantly base metal D6792 Crown full cast noble metal D6930 D6980 Recement fixed partial denture Fixed partial denture repair necessitated by restorative material failure D9940 Occlusal guard, by report 1 in 12 for members 13 years and older (4) Class IV: Orthodontic Services (Medically Necessary Orthodontic Treatment) This plan does not provide an orthodontic benefit except for Medically Necessary Orthodontic Treatment. Medically Necessary Orthodontic Treatment is defined as those circumstances where the Member s condition creates a medical disability and impairment to their overall physical development. DentaQuest s licensed dentists/specialists will review requests and make determinations. There is a waiting period of 24 from the Effective Date of coverage for each Member under this Policy before that Member becomes eligible for Medically Necessary Orthodontic Treatment. The following is a list of Covered Services for Medically Necessary Orthodontic Treatment _PHP_SOBDental_
17 Class IV Services: Orthodontic Services (Medically Necessary Orthodontic Treatment) D0340 Cephalometric radiographic image D0350 Oral/facial photographic images obtained intraorally or extraorally D8010 Limited orthodontic treatment of the primary dentition D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition D8050 Interceptive orthodontic treatment of the primary dentition D8060 Interceptive orthodontic treatment of the transitional dentition D8070 Comprehensive orthodontic treatment of the transitional dentition D8080 Comprehensive orthodontic treatment of the adolescent dentition D8210 Removable appliance therapy D8220 Fixed appliance therapy D8660 Pre-orthodontic treatment visit D8670 Periodic orthodontic treatment visit (as part of contract) D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) Adult Dental Services Coverage for adult dental services are limited to the Class I and Class II Covered Services listed below. The plan will cover up to $500 in Covered Services per Plan Year. (1) Class I Services: Diagnostic and Preventive Services Benefits are available for the following dental services to diagnose or to prevent tooth decay and other forms of oral disease: Class I Services: Diagnostic and Preventive Services D0120 Periodic oral evaluation established Once in 6 $0 patient D0140 Limited oral evaluation problem focused Once in 6 D0150 Comprehensive oral evaluation new or established patient Once in _PHP_SOBDental_
18 Class I Services: Diagnostic and Preventive Services D0180 Comprehensive periodontal evaluation Once in 6 $0 new or established patient D0210 Intraoral complete set of radiographic images Once in 60, including bitewings D0220 Intraoral periapical first radiographic image D0230 Intraoral periapical each additional radiographic image D0240 Intraoral occlusal radiographic image D0270 Bitewing single radiographic image 1 set every calendar year D0272 Bitewings two radiographic images 1 set every calendar year D0274 Bitewings four radiographic images 1 set every calendar year D0277 Vertical bitewings 7 to 8 radiographic 1 set every calendar year images D0330 Panoramic radiographic image Once in 60 D0470 Diagnostic casts D1206 Topical application of fluoride varnish Once in 12 D1208 Topical application of fluoride Once in 6 D9110 Palliative (emergency) treatment of dental pain minor procedure 3 times per year with supporting documentation (2) Class II Services: Restorative and Other Basic Dental Services Benefits are available for the following dental services to treat oral disease: Class II Services: Restorative and Other Basic Dental Services D0391 D2140 D2150 D2160 D2161 D2330 D2331 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report Amalgam one surface, primary or permanent Amalgam two surfaces, primary or permanent Amalgam three surfaces, primary or permanent Amalgam four or more surfaces, primary or permanent Resin-based composite one surface, anterior Resin-based composite two surfaces, anterior 65441_PHP_SOBDental_
19 Class II Services: Restorative and Other Basic Dental Services D2332 D2335 Resin-based composite three surfaces, anterior Resin-based composite four or more surfaces or involving incisal angle (anterior) D2910 Recement inlay, onlay or partial coverage restoration D2920 Recement crown D2929 Prefabricated porcelain/ceramic crown primary tooth Once per tooth per 24 on anterior primary teeth D2940 Protective restoration D2951 Pin retention per tooth, in addition to restoration D4341 Periodontal scaling and root planing four or more teeth per quadrant Limited to 1 every 24 D4342 Periodontal scaling and root planing one to three teeth per quadrant Limited to 1 every 24 D4910 Periodontal maintenance 4 in 12 combined with adult prophylaxis after the completion of active periodontal therapy D5410 Adjust complete denture maxillary D5411 Adjust complete denture mandibular D5421 Adjust partial denture maxillary D5422 Adjust partial denture mandibular D5510 Repair broken complete denture base D5520 Replace missing or broken teeth complete denture (each tooth) D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5710 Rebase complete maxillary denture (after 6 have elapsed since initial placement) D5720 Rebase maxillary partial denture (after 6 have elapsed since initial placement) 65441_PHP_SOBDental_
20 Class II Services: Restorative and Other Basic Dental Services D5721 Rebase mandibular partial denture (after 6 have elapsed since initial placement) D5730 D5731 Reline complete maxillary denture (chairside) Reline complete mandibular denture (chairside) after 6 elapsed. (3 from after 6 elapsed. (3 from D5740 Reline maxillary partial denture (chairside) after 6 elapsed. (3 from D5741 D5750 D5751 Reline mandibular partial denture (chairside) Reline complete maxillary denture (laboratory) Reline complete mandibular denture (laboratory) after 6 elapsed. (3 from after 6 elapsed. (3 from after 6 elapsed. (3 from 65441_PHP_SOBDental_
21 Class II Services: Restorative and Other Basic Dental Services D5760 D5761 Reline maxillary partial denture (laboratory) Reline mandibular partial denture (laboratory) after 6 elapsed. (3 from after 6 elapsed. (3 from D5850 Tissue conditioning, maxillary Once per 60 per arch D5851 Tissue conditioning, mandibular Once per 60 per arch D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7270 D7280 D7310 D7311 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated Removal of impacted tooth soft tissue Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony, with unusual surgical complications Surgical removal of residual tooth roots (cutting procedure) Coronectomy intentional partial tooth removal Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth Surgical access of an unerupted tooth Alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per quadrant Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant 65441_PHP_SOBDental_
22 Class II Services: Restorative and Other Basic Dental Services D7320 D7321 D7471 Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant Removal of lateral exostosis (maxilla or mandible) D7510 Incision and drainage of abscess intraoral soft tissue D7910 Suture of recent small wounds up to 5 cm Individual consideration D7921 D7971 D9220 D9221 D9241 D9242 D9610 D9930 Exclusions Collection and application of autologous blood concentrate product Excision of pericoronal gingiva Deep sedation/general synesthesia first 30 minutes Deep sedation/general anesthesia each additional 15 minutes Intravenous conscious sedation/analgesia first 30 minutes Intravenous conscious sedation/analgesia each additional 15 minutes Therapeutic parenteral drug, single administration Treatment of complications (post-surgical) unusual circumstances, by report Individual consideration The exclusions in this section apply to all pediatric dental services and adult dental services benefits. Although We may list a specific service as a benefit, We will not cover it unless DentaQuest and/or We determine it necessary for the prevention, diagnosis, care or treatment of a covered condition. The following are not covered under this plan s pediatric dental services or adult dental services benefit: Services and treatment provided or commenced prior to the effective date of the Member s coverage under the Policy or after the termination date of coverage unless otherwise indicated. Services and treatment not described as a Covered Service in this Schedule of Benefits Dental. (See the section Covered Services for a list of services and treatment that are covered under this plan.) Dental procedures, services, treatment or supplies not prescribed or under the direct supervision of a dentist. Experimental or investigational services and treatments. Services and treatment which are for any Illness or Bodily Injury which occurs in the course of 65441_PHP_SOBDental_
23 Schedule of Benefits Dental employment if a benefit or compensation is available, in whole or part, under the provision of any law or regulation or any government unit. This exclusion applies whether or not You claim the benefits or compensation. Services and treatment received from a dental or medical department maintained by or on behalf of an employer, mutual benefit association, labor union, trust, Veterans Administration hospital or similar person or group. Services and treatment which are not dentally necessary or which do not meet generally accepted standards of dental practice. Services and treatment resulting from your failure to comply with professionally prescribed treatment. Telephone consultations. Any charges for failure to keep a scheduled appointment. Any services that are considered strictly cosmetic in nature including, but not limited to, charges for personalization or characterization of prosthetic appliances. Services related to the diagnosis and treatment of temporomandibular joint dysfunction (NOTE: these benefits may be covered as a medical benefit. Please see Your Policy for more information). Services or treatment provided as a result of Injuries suffered while committing or attempting to commit a felony, engaging in an illegal occupation or participating in a riot, rebellion or insurrection. Office infection control charges. Charges for copies of Your records, charts or x-rays or any costs associated with forwarding/mailing copies of Your records, charts or x-rays. State or territorial taxes on dental services performed. Those submitted by a dentist, which is for the same services performed on the same date for the same Member by another dentist. Those provided free of charge by any governmental unit, except where this exclusion is prohibited by law. Those for which the member would have no obligation to pay in the absence of this or any similar coverage. Those which are for specialized procedures and techniques. Those performed by a dentist who is compensated by a facility for similar covered services performed for Members. Duplicate, provisional and temporary devices, appliances and services. Plaque control programs, oral hygiene instruction and dietary instructions. Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation and restoration for misalignment of teeth. Gold foil restorations. Treatment or services for Injuries resulting from the maintenance or use of a motor vehicle if such treatment or service is paid or payable under a plan or policy of motor vehicle insurance, including a certified self-insurance plan. Treatment of services for injuries resulting from war or act of war, whether declared or undeclared, or from police or military service for any country or organization. Hospital costs or any additional fees that the dentist or hospital charges for treatment at the hospital (inpatient or outpatient). Charges by the Provider for completing dental forms _PHP_SOBDental_
24 Adjustment of a denture or bridgework which is made within six (6) after installation by the same dentist who installed it. Use of material or home health aids to prevent decay, such as toothpaste, fluoride gels, dental floss and teeth whiteners. Sealants for teeth other than permanent molars. Precision attachments, personalization, precious metal bases and other specialized techniques. Replacement of dentures that have been lost, stolen or misplaced. Orthodontic services provided to a Dependent of an enrolled Member show has not met the 24 month waiting period requirement. Orthodontic care for Dependent Children age 19 and over. Repair of damaged orthodontic appliances. Replacement of lost or missing appliances. Fabrication of athletic mouth guard. Internal bleaching. Nitrous oxide. Oral sedation. Topical medicament center. Orthodontic care not covered under this Scheduled of Benefits Dental and the Policy. Bone grafts when done in connection with extractions, apicoetomies or non-covered/noneligible implants. When two (2) or more services are submitted and the services are considered part of the same service to one another We will pay the most comprehensive service (the service that includes the other non-benefited service) as determined by Us. When two (2) or more services are submitted on the same day and the services are considered mutually exclusive (when one service contradicts the need for the other service), We will pay for the service that represents the final treatment as determined by Us. All out-of-network services except as provided under this Schedule of Benefits Dental and the Policy _PHP_SOBDental_
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